By Drew Altman
The New York Times, January 5, 2017
This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump — people who are enrolled in the very health care marketplaces created by the law — one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.
Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.
The Kaiser Foundation organized six focus groups in the Rust Belt areas — three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn’t really know what he would do, and were worried about what would come next.
They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance — for which they were eligible for subsidies — saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters.
The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act — including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage — several of these Trump voters recoiled, calling such proposals “not insurance at all.” One of those plans has been proposed by Representative Tom Price, Mr. Trump’s nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.
When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called “chaos” if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, “a smart businessman like Trump would let that happen.”
There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as “un-American.”
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.
Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.
In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.
By Don McCanne, M.D.
This survey of focus groups composed of Trump supporters confirms the anecdotal reports that many of them have been disappointed by Obamacare, but they want health insurance that is affordable and that works. They believe that President Trump will do the right thing even though they have no idea what that is.
Although they have a poor understanding of the complexities of insurance, what they do want is to keep their out-of-pocket costs low, control drug prices, improve access to cheaper drugs, eliminate surprise medical bills for out-of-network care, adequate provider networks, and make their insurance more understandable. What they seem to want are the policies of a single payer national health program. What they certainly would not want would be any of the replacement proposals of the Republican party if they understood how much worse affordability and access would be.
What we need are the replacement bills so that we can explain the damage they would do, but it appears that those bills are not forthcoming.
What we will probably see is a resolution, but not a requirement, to repeal features of Obamacare at some time in the distant future. The Republicans may then introduce replacement bills which they will tout as reform but will actually advance intolerable changes (privatizing Medicare, slashing Medicaid funding through block grants, establishing high risk pools without adequately funding them, etc.) that the Democrats will have to filibuster. Then the Republicans will be able to claim that they tried to replace Obamacare, but the Democrats blocked their reforms. They can then walk away, hoping everyone will have forgotten their resolution to repeal Obamacare.
The problems that people are blaming on Obamacare will still be there, even though they are mostly problems inherent in the highly flawed, fragmented financing infrastructure that was only minimally patched by Obamacare. When they see that the “repeal and replace” rhetoric was all hot air, they may be ready to accept an insurance program that they can understand and that will meet their needs – a single payer, improved Medicare for all.